To change the culture, start with clinical education

The hardest thing about medical school isn’t learning medicine. It isn’t the hours. It isn’t the tests. It’s that you sign away control over years of your adult life.

When I started my clerkship year in January, I felt like I was stepping onto a conveyor belt and would not be allowed off for twelve long months. For the entirety of 2018, my days are planned for me, my hours are set, and my attendance is mandatory. I have the distinct feeling that this year is happening to me. My classmates and I are currently marching through a pre-determined set of rotations, the lowest-ranking members on every team we are a part of. What this translates to is a year in which we no longer even have control over when we go to the bathroom. We joke about the kidney injuries we have no doubt sustained rounding and retracting for hours. We joke about it because there isn’t really anything else we can do. Better to take a hit to our creatinine than take the risk of complaining to the same people who are evaluating us.

As we approach the halfway point in the year, I have watched my friends grow increasingly disenchanted with and frustrated by their experiences in the hospital. A friend who was dead-set on going into OB/GYN is having to rethink her future after spending six weeks being belittled and ignored on her OB/GYN clerkship. Multiple friends have been blindsided when they discovered that residents who’d given them nothing but praise during their medicine clerkship had absolutely slammed them in their final evaluations. Another friend has been so put off by the lack of concern for our well-being that he very well might not do a residency at all.

There’s no reason it has to be like this, and yet it seems like every month we see a headline about a medical student or resident committing suicide. It’s no secret that depression and anxiety are common in medicine, but that knowledge has yet to spark any meaningful discussion of what is driving members of our community to kill themselves and what we can do to change that. We continue to operate in a system that denies you any control over your own time and offers you little reprieve short of dropping out of it entirely. It’s a system in which you feel very small and very powerless to question the way things are done. It’s not surprising to me that some people feel there’s no way out.

“Wellness” has become a bit of a buzzword in medicine, but that hasn’t translated into substantive changes. While schools have made an effort to reduce stress and adopt new teaching methods during the pre-clinical years, the basic structure of the clerkship year has gone unchanged for over a century. After 18 months in which our education was our school’s primary focus, my classmates and I are now experiencing a very different educational model. As clerkship students, we are shunted from team to overworked team, filling a role that is typically redundant and frequently unclear. Unsurprisingly, our education often feels like the lowest priority.

We are also now subject to an arbitrary and opaque system of evaluation, in which your grades can be more dependent on who you work with than your actual performance. There is plenty of evidence demonstrating bias against women and minorities in these subjective evaluations, but there has yet to be any real movement to improve that system and protect against those sorts of biases, not to mention reduce the student burnout they engender. It is difficult to stay focused on the task at hand — learning to be a doctor — with the sense that you are ultimately rewarded not for your ability to care for patients but for your ability to meet the often conflicting expectations of the members of your team.

I still love medicine. For every negative experience I’ve had, I’ve had many more positive ones. I’ve worked with residents and attendings who genuinely value my contributions and prioritize my learning. I’ve helped take care of patients who have reinforced why I was drawn to medicine in the first place, and I’ve learned more in the several months I’ve spent on the wards than I would have thought possible. It’s because I love this field so much that I’ve been so disappointed by the culture I’m now learning to assimilate to. I can’t wait to be a doctor, but I worry that by the time I get there I’ll have lost so much of the enthusiasm and intellectual curiosity that have gotten me this far.

My classmates and I all talk about how once we’re residents, we’ll treat our medical students fairly and compassionately, but I can’t imagine that the residents we are working now with had dreamed of becoming capricious and unempathetic. So what changes between now and then? Will we lose sight of our values and perpetuate the same unfriendly system as we begin to ascend the ranks? What will it take to change the prevailing view that medicine is something you have to suffer for? I have no problem with hard work, but as a very tiny cog in a very large machine, I have never felt like I had so little autonomy. It’s that sense of disempowerment — more so than shelf exams or 5 a.m. wake-up times — that is beginning to wear away at my love for this field. I don’t think I’m the only one.

The author is an anonymous medical student.

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